Key messages
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Tranexamic acid given as a preventive treatment makes little to no difference to heavy bleeding after vaginal birth.
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We are uncertain about whether there are any harmful effects from tranexamic acid.
What is the issue?
Postpartum haemorrhage, which is heavy bleeding after giving birth, is a common and potentially life-threatening complication of birthing a child. Most women receive drugs (called uterotonics) that stimulate the womb to contract after a normal (vaginal) delivery to prevent postpartum haemorrhage. Tranexamic acid (TXA) is a medication that is used to decrease blood loss in surgery and health conditions associated with increased bleeding. It works by helping to prevent the breakdown of blood clots. If a woman is bleeding heavily after birth, it decreases blood loss. We do not know if TXA can help prevent heavy bleeding after vaginal birth.
What did we want to find out?
We wanted to know whether fewer women have heavy bleeding after a vaginal birth if they receive TXA, with or without additional uterotonics, during vaginal birth. We also wanted to find out if taking TXA during vaginal birth was associated with any harmful effects.
What did we do?
We searched for and selected all the studies that addressed our question. We used a checklist to make sure we only included studies with information we could verify. We made judgements about the quality of the studies before comparing and summarising the results of the studies. Lastly, we rated our confidence in the findings.
Why is this important?
It is important to determine whether TXA is effective in preventing heavy bleeding after birth when given to women during vaginal birth. If there is a benefit, it could help women around the world and even play a role in reducing the number of women who die after giving birth.
How up to date is this evidence?
We searched for all available evidence up to 6 September 2024.
What evidence did we find?
We identified three studies that investigated the effects of preventive TXA. The three studies involved a total of 18,974 participants at low or high risk of heavy bleeding. Participants were given either intravenous (into a vein) TXA plus standard care or placebo (saline) injection plus standard care.
We found that preventive TXA results in little to no difference in heavy bleeding after birth.
We are very uncertain about the effect of TXA on maternal death. TXA likely makes no difference to the risk of women developing serious illness.
We found that TXA has no effect on the likelihood of receiving a blood transfusion. TXA may result in no difference in the need for further surgical intervention after giving birth. We are very uncertain about the effect of TXA on blood clots. In women with anaemia, TXA makes no difference to the need for additional drugs to help the womb contract, but in women with no anaemia, there was a slight reduction in this outcome. We are very uncertain about the effect of TXA on hysterectomy (an operation to remove the womb). There does not seem to be a difference in maternal satisfaction.
What are the limitations of the evidence?
The studies included women in both high- and low-resource settings. Few women experienced harmful effects. However, we cannot be certain that this is indeed the case in the real world.
What does this mean?
We found no difference in the number of women experiencing heavy bleeding after birth after they were given TXA preventatively during vaginal birth, and we are very uncertain about the effect of TXA on blood clots and other serious side effects. As these are harmful effects, clinicians should take into account the lack of benefit and the potential harms when considering giving routine TXA to women during vaginal birth.
Further research should focus on other interventions that may help to prevent heavy bleeding after vaginal birth.
Read the full abstract
Objectives
To assess the effects of TXA for preventing PPH compared to placebo or no treatment (with or without uterotonic co-treatment) in women following vaginal birth.
Search strategy
We searched MEDLINE, Embase, CENTRAL, and WHO ICTRP (to 6 September 2024). We also searched reference lists of retrieved studies.
Authors' conclusions
Adding prophylactic TXA to standard care of women during vaginal birth makes little to no difference to blood loss ≥ 500 mL and likely makes little to no difference to blood loss ≥ 1000 mL or the risk of severe morbidity, compared to placebo and standard care.
TXA may result in little to no difference in additional surgical interventions to control PPH and results in little to no difference in blood transfusions. One trial found that TXA reduced the use of additional uterotonics in women without anaemia, whereas the largest trial found little to no difference in the use of additional uterotonics in women with anaemia.
Although there were very few serious adverse events reported, the evidence is insufficient to draw conclusions about the effect of TXA on maternal death, thromboembolic events, hysterectomy, or seizures.
TXA likely results in little to no difference in maternal satisfaction.
These findings are based mainly on two large trials. In the smaller of these, less than 30% of study participants were at high risk of PPH. In the largest trial, all participants had moderate to severe anaemia.
Those making decisions about routine administration of prophylactic TXA for all women having vaginal births should consider that current evidence does not show a benefit of TXA for blood loss outcomes and related morbidity, and the evidence is very uncertain about serious adverse events.
Funding
This review was partially funded by the World Health Organization (WHO).
Registration
Protocol (2009) DOI: 10.1002/14651858.CD007872
Original review (2010) DOI: 10.1002/14651858.CD007872.pub2
Review update (2015) DOI: 10.1002/14651858.CD007872.pub3
